1985, 03-14 Permit App: 00004481 Plumbing Fixtures A,1! PLUMBING PERMIT APPLICATION WORKSHEET
j PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
c&(-Tin( elle 1*- J Project No.
2 Project Address(Not Mailing Address) Space Zip
703 ,.glc9 C y Z ( f
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block .
/
r/
16 Contractor Firm Name Street Address
Gold Seal Mechanical, Inc. 13203 E. Forrest
17 Zip I City State Phone
99216 Spokane Wa 509 )924 3423
18 Contact Person 1 License No. Phone if different than above
R. Dixon GO LD SM 290C4
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
Total Number
15 Describe Work: New ❑ ; Addition/Alteration ❑ ; Replace/Repair ❑ /y
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
( )
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): , Washing Machine(s): /
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s):
(
Lndry Tray(s): Sew Eject(s):
11 Urinal(s): WtrCloset(s): 3 Lav(s): 9 Shower(s): 2 Tub(s): t Bidet(s):
w Other: Type;
W
CC
0
I- 12 Waste/Grease Interceptor(s):
L
0
O 13 Sewer Y N Septic/Health No.:
CC
W
CCI 14 Electric Water Heater(s): Drains-Roof:
D
Z 15 REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s),including backflow device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5: (Or)5+:
caG
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF 4111 Air APPLICATION -(Y_ S
OWNER OR AGENT DATE